Practitioners advise on using hyaluronic acid to treat the lower face in men
As aesthetic clinicians, you will be familiar with the increased interest from your female patients in jawline treatment over the past couple of years. Global statistics indicate that there has been a steady rise in the number of people searching the web for ‘jawline’, along with related topics such as ‘how to get a defined jawline’ and ‘sharper jawline’, while the UK and Ireland are among the top five countries where the searches are most popular on Google.1
With that said, a chiselled jawline and strong chin have always been ‘on trend’ and desired by men across the globe. A study from 2019 on the psychological desires of facial appearance amongst men indicated that, along with a straight nose, there is a high demand for a prominent jawline and gonial angle.2
This has largely been attributed to the fact that people perceive men with stronger jawlines as being more competent, successful and attractive.3-6 Aesthetic practitioner Dr Sophie Shotter explains, “Research shows that a strong, defined jawline is seen as synonymous with good leadership skills and dominance in men. A softly defined and rounded jawline is deemed to be more feminine. The reason for this is that high testosterone levels give men this underlying structure, and so subconsciously we perceive men with strong jawlines as having high testosterone levels and being more masculine.”
While surgery has been the traditional approach for lower face definition, there is now a multitude of non-surgical or minimally-invasive treatments that can offer noticeable and long-lasting results, independently or in combination with each other. Aesthetic practitioners can choose to treat their patients with a range of procedures, however this article will focus on the use of hyaluronic acid (HA). We speak to Dr Shotter, Dr Paul Baines and Dr Armand Abraham about the products they use, their male-specific technique approaches, and how they recommend practitioners successfully manage the expectations of male patients.
Approximately 10% of Dr Shotter’s patients are men; a figure that has been growing year on year. The same goes for Dr Baines, whose male patients make up around 20% of his database. Men make up a significantly larger proportion of Dr Abraham’s patient base – more than 70%. He says these are mainly accumulated from word-of-mouth recommendations amongst the gay community. “Being a part of this community has meant that I’ve built my database organically and am trusted amongst my patients – it wasn’t planned but is something I’m proud of,” he says, noting that his male patients are becoming increasingly confident with seeking treatment.
All practitioners agree that while men will usually be very confident in their choice of clinician, they’re generally less informed on the types of treatment available to them. Dr Baines explains, “As a stereotype, they’ve researched who they’re going to entrust their treatment to, and then once they’re in clinic, it’s pretty much a case of, ‘I trust you as a clinician to make me look as good as you possibly can and do what you think is best’.
Dr Shotter adds, “The men I see have usually been considering treatment for a long period of time but, for the most part, are less knowledgeable about treatment options than women. They have often had a concern for many months or even years, and decided to come and see what may be done about it, but are generally less aware of a particular treatment option than my average female patient.” While this can offer more freedom to discuss a variety of options,
Dr Abraham notes that it can make it more challenging for practitioners to avoid leading the patient to addressing particular concerns or undergoing certain treatments. “Men will come to clinic and ask, ‘What treatment do you think I should have?’, which one needs to approach in a very careful manner. You don’t want make them conscious of something that they’re actually comfortable with,” he says, advising, “I respond by asking questions such as, ‘What is it that you’re not comfortable with?’ And, ‘What is it that you see that you would like to improve or enhance?’.
On a positive note, Dr Baines says that male patients are a lot more loyal than female patients. “I’ve never lost a male patient or had one that shops around – when they jump in they’re all in and are generally more open to a diverse range of treatments,” he says, highlighting, “I don’t think that’s exclusive to aesthetics; men tend to be quite loyal and put their trust in things once they’ve found something that works for them. Think of barbers – men are known to keep returning to their same barber for their whole life!”
When men attend consultation, practitioners find that their main worry with undergoing aesthetic treatment is the risk of feminisation. “Avoiding this is their number one priority,” says Dr Baines, noting that men don’t want to look treated at all so effective communication on how you achieve this is key.
Dr Shotter adds, “Treating the jawline and chin without understanding male vs. female anatomy could lead to feminisation rather than masculinisation. It’s important to study the proportions that make a face look masculine or feminine, before creating a treatment plan.”
Dr Baines says that during the consultation he explains how the male face ages, how it can be masculinised and how it differs to the female face. He says, “I talk them through how the mentum is wider; approximately the whole width of the mouth rather than the central two thirds seen in women. The bigonial distance is wider as well, which means men can carry off a sharper, fuller and heavier jaw. I then outline the ageing process, discussing skin laxity and bony resorption, and how we can address this in multiple ways.”
Dr Shotter notes that it is also important to take the mid-face into consideration, highlighting, “I always start by assessing the mid face – treating the cheeks will alter the jawline, and so I assess whether some mid-face support is needed first.”
As with any patient, looking at their individual facial shape is imperative. Dr Baines emphasises, “You should always be looking to enhance the features someone has already, rather than change it. It’s also all about the communication to work out what the patient wants and the best plan of action.”
Aesthetic practitioner Dr Raul Cetto detailed the anatomical features and ageing process of the male jawline in his article ‘Male Chin and Jawline Ageing’, published by Aesthetics.5 His top five tips to remember are:
1. The male chin width corresponds to the width of the mouth and female chin to the width of the alar base.
2. Male patients have a broader bigonial width, whereas the female bigonial width only increases with age.
3. The jowl is the superficial fat which enlarges as part of the ageing process and disrupts the jawline; it is import to volumise away from this area of heaviness.
4. The facial artery emerges deep and anterior to the border of the masseter muscle. Injections for contouring the jawline should be placed superficially and away from the artery.
5. The contour of the chin is defined by the superficial fat, so in order to enhance the chin, deep injections are indicated in the midline to restore anterior or inferior projection. However, most of the product should be placed superficially in order to redefine and contour.
When choosing appropriate products to treat patients with, Dr Baines highlights that it’s important to remember facial proportions, the differences in chin shape between men and women, and skin thickness in men, in order to achieve the best result most efficiently. Dr Abraham adds that practitioners should consider the layer in which they intend to inject, as well as, of course, the reputation and safety data of the products available.
Dr Baines advocates the use of products with a high G-prime as the higher degree of thickness means it will be firmer and more contour stable. “If you’re using a product with a low G-prime, you’re likely to need much more of it; whilst this may be acceptable for some women, the volumes required for typical male treatments would be significantly higher.” His products of choice come from the Restylane range. “The high G-prime of the NASHA products mean that men will get a greater amount of lift per ml, as well as good coverage for the amount of volume placed,” he explains.
Dr Shotter says, “My preference for treating the jawline is to use Juvéderm Volux. This product was specifically designed for this area – it is a structural HA gel giving enhanced projection and lift. I find the results are beautiful, giving a better ’sculpt’ than products I previously used for this area. Patient satisfaction is very high; both because of the results and the longevity.”
Alternatively, Dr Abraham uses the STYLAGE range. He says, “When it comes to the jawline, I have very good results using STYLAGE XL and XXL to enhance the angle of the mandible and project the chin. They give very good support for this area in men.”
When it comes to treatment, Dr Shotter says that after assessing the mid-face, she will then look at the chin. She considers whether there is retrognathia, if the chin length is in proportion to the rest of the face, and what the width of the chin is. She notes, “In a man I will aim for the chin to be approximately the width of the lips, whereas in a female I will aim for the chin to be the width of the nose.”
Following this, Dr Shotter explains that she will assess the width of the jaw in comparison to the width of the cheekbones. “It is widely acknowledged that in men, the bigonial width should be approximately the same as the interzygomatic width,” she explains, adding, “I often strengthen and widen the jaw angle with a bolus of product laid on bone with needle.”
It’s also important to assess whether there is a weakness in the length of the mandible, Dr Shotter notes; for which she may consider laying a second bolus with needle onto the posterior aspect of the ramus of the mandible. “This can give a more angular appearance as well as helping to reduce jowling,” she explains, adding, “I will almost always strengthen the anterior aspect of the mandible using linear threads with a cannula in the subcutaneous plane. Occasionally I may also lay a bolus with needle on bone in the pre-jowl area if there is a deficit here. If more sharpness is desired I may define along the length of the body of the mandible using a cannula in the subcutaneous plane.”
Dr Abraham will first consider whether the patient will benefit from jawline slimming using botulinum toxin. “Some patients will have a more rounded jawline shape as a result of a thick masseter muscle or bruxism. Relaxing the muscle first will make it appear slimmer, which will help with the overall redefinition,” he explains, adding it can also benefit indicated patients with a smaller budget as it will mean less HA is needed later.
Once the toxin has settled and a result is noticeable, Dr Abraham sees the patient again for their HA treatment. “On average I would use 2-2.5ml of HA on each side in men where treatment of the jawline and chin goes hand in hand; I use it to redefine the corners by injecting boluses onto the periosteum at the angle of the mandible, before using a straight linear injecting technique along the arms of the mandible with a 23 gauge cannula, to achieve a stronger jawline and injecting a bolus of 0.3ml on the surface of the mental processes to square the chin,” he explains, adding, “I sometimes use STYLAGE L, which is less viscous, and inject with a cannula very carefully subcutaneously on top of the most laterally projected part of the lower third of the masseter muscle.”
Dr Baines shares his approach to treating one patient in particular (Figure 3). He explains, “This patient wanted a more striking appearance so more product was used than usual (here the volume used was 7mls, compared to typically 3 or 4) but it gave a very effective result. It was achieved by injecting 1.5ml of Restylane Lyft into the mentum anteriorly, 1.5ml either side of the jawline: 0.75ml behind the jowl in a linear fashion plus 1ml at the angle of the mandible placed deeply on the periosteum, followed by a final 1ml on the zygoma bilaterally to define the cheek.” Dr Baines notes that this patient particularly requested cheek definition, but reminds practitioners the risk of feminisation is higher when treating the cheeks so conservative volumes with continuous assessment is important.
Continuing with Dr Baines’ advice on avoiding feminisation, he recommends reviewing the patient’s face throughout the procedure in a sitting position. “Inject small amounts and frequently recheck the effect while the patient is upright, involving them in the review, so you both have an understanding of the direction the treatment is heading and can stop when appropriate,” he says.
If you do realise that you’re getting too much overfill in an area, the first thing you should do is massage the product, advises Dr Baines, explaining, “You can usually flatten down the amount of lift with some firm pressure, as long as the volume you’ve placed isn’t very much.” He continues, “Of course if that doesn’t make a difference, with HA, you always have the option of dissolution with hyaluronidase. Whilst this is a reassuring safety-net that patients find reassuring, it should be remembered that this is an off-licence use of hyaluronidase and shouldn’t be something to rely on. Thankfully, this isn’t something that I have needed to use.”
A thorough understanding of male facial anatomy and injection techniques, combined with a thorough consultation process is vital says Dr Baines, adding, “If expectations aren’t fully met, I would recommend allowing a few days for swelling to settle and tissue integration to occur. Review at a week will usually have seen sufficient improvement to avoid the need to dissolve the HA.”
Dr Armand notes that when it comes to the jawline, patients sleeping on their side can cause product redistribution. He advises patients to sleep on their back for three nights, and if they do notice this issue to lightly massage the area to reposition the filler to where it should be as he showed them after treatment. He adds, “Of course I advise them not to massage the area normally and if they notice a significant redistribution or any other problems, the patients are instructed to contact me immediately.”
Normal aftercare advice and discussion of potential complications is imperative for all patients, but Dr Shotter notes that facial hair on men is a key difference that should be considered. She says, “I ask men to refrain from shaving for 48 hours whilst the initial product swelling settles. I otherwise give the same advice – to not touch the face post treatment, to avoid massaging the face for two weeks after treatment, avoid intense exercise for 48 hours, and to avoid intense heat for two weeks. Additionally, no alcohol should be consumed on the night of treatment.”
Men tend to follow aftercare advice very strictly, highlights Dr Baines, explaining, “If you give them a list of what they can and can’t do very explicitly, they tend to follow it to the letter, more so than women in my experience. Men like to have clear of list of what to look out for, any red flags, and knowing they can contact you if needed.”
For those looking to develop their skills and start treating more men, Dr Armand recommends practising on friends and family, as well as taking male models on any training courses you attend, with an offer of free or consumables only cost treatment. He advises to always take high-quality before and after photographs, requesting permission from the male patient to use in your marketing. “When describing the treatment alongside your images, I use more description for men than women as they tend to want more detail and extra reassurance that this treatment is suitable for them, as well as women,” he notes.
Dr Armand adds that if practitioners have spent a long time solely treating women, they should be wary of their natural aesthetic eye. “It’s inevitable that you will approach the male face in the same way as you do the female face when you first start assessing men,” he says, explaining, “Every practitioner develops their own aesthetic eye when it comes to observing symmetries, corners and curves of the face, and if your eye is used to women’s faces then it is only natural that this will happen. Remember – it needs to be avoided. Take a step back, remind yourself of the differences in facial anatomy and reaffirm your end goal.”
He concludes, “Men will be apprehensive of treatment and may be harder to attract to your clinic, but remember it falls on us as practitioners to provide reassurance that there are indications for them, particularly with the jawline and chin, and we can help them. There is a huge market for male patients, so we as clinicians should get out of our comfort zone and tell men that we are here for them when they need us.”
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